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The CPT® Code 96161 refers to the administration of a caregiver-focused health risk assessment instrument, which is designed to evaluate the health risks faced by a caregiver that may impact their ability to support a patient effectively. This assessment is particularly important as it identifies potential issues such as depression or other health concerns in caregivers, which can significantly affect the quality of care they provide. The process involves using a standardized questionnaire that is typically administered in a face-to-face setting. During this interaction, the interviewer records the caregiver's responses, which are then scored using a standardized tool. The scoring helps to quantify the level of health risk associated with the caregiver's responses. The results of this assessment are crucial as they are shared with both the patient and the caregiver, allowing for informed discussions about health risks and the necessary interventions. Based on the findings, a health plan may be developed or adjusted to ensure that both the caregiver and the patient receive appropriate clinical preventive care, health promotion, and disease management. This comprehensive approach not only addresses the caregiver's health but also enhances the overall support system for the patient.
© Copyright 2025 Coding Ahead. All rights reserved.
The caregiver-focused health risk assessment instrument (CPT® Code 96161) is indicated for use in various scenarios where the health and well-being of a caregiver may impact their ability to provide adequate support to a patient. The following conditions and situations warrant the administration of this assessment:
The procedure for administering the caregiver-focused health risk assessment instrument involves several key steps that ensure a thorough evaluation of the caregiver's health risks. Each step is crucial for obtaining accurate and actionable data.
After the administration of the caregiver-focused health risk assessment instrument, several post-procedure considerations are important for ensuring effective follow-up and care. The healthcare provider should ensure that the caregiver receives a copy of the assessment results and the proposed health plan. It is essential to schedule follow-up appointments to monitor the caregiver's health and the effectiveness of the implemented health plan. Additionally, ongoing support and resources should be provided to the caregiver to address any identified health risks, such as referrals to mental health services or support groups. This comprehensive approach helps to maintain the caregiver's well-being, which is vital for the continued support of the patient.
| Short Descr | CAREGIVER HEALTH RISK ASSMT | Medium Descr | CAREGIVER HLTH RISK ASSMT SCORE DOC STND INSTRM | Long Descr | Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 5 - Incident To Code | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Not Discounted when Multiple | Berenson-Eggers TOS (BETOS) | M5D - Specialist - other | MUE | 1 |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 99202 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. | 99203 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99204 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. | 99205 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. | 99211 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional | 99212 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. | 99213 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. | 99214 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99215 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. | 99221 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. | 99222 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. | 99223 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. | 99231 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. | 99232 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. | 99233 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. | 99234 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. | 99235 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded. | 99236 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded. | 99238 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter | 99239 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the encounter | 99242 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. | 99243 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99244 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. | 99245 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. | 99252 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. | 99253 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. | 99254 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. | 99255 | Telemedicine Service (AMA) MPFS Status: Not valid for Medicare purposes APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded. | 99281 | Telehealth Service (Medicare) MPFS Status: Active Code APC J2 Physician Quality Reporting PUB 100 CPT Assistant Article Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional | 99282 | Telehealth Service (Medicare) MPFS Status: Active Code APC J2 Physician Quality Reporting PUB 100 CPT Assistant Article Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making | 99283 | Telehealth Service (Medicare) MPFS Status: Active Code APC J2 Physician Quality Reporting PUB 100 CPT Assistant Article Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making | 99284 | Telehealth Service (Medicare) MPFS Status: Active Code APC J2 Physician Quality Reporting PUB 100 CPT Assistant Article Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making | 99285 | Telehealth Service (Medicare) MPFS Status: Active Code APC J2 Physician Quality Reporting PUB 100 CPT Assistant Article Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making | 99288 | MPFS Status: Bundled Code APC B PUB 100 CPT Assistant Article Physician or other qualified health care professional direction of emergency medical systems (EMS) emergency care, advanced life support | 99291 | Telehealth Service (Medicare) MPFS Status: Active Code APC J2 Physician Quality Reporting PUB 100 CPT Assistant Article Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes | 99292 | Telehealth Service (Medicare) Addon Code MPFS Status: Active Code APC N Physician Quality Reporting PUB 100 CPT Assistant Article Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) | 99304 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. | 99305 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. | 99306 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. | 99307 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. | 99308 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. | 99309 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99310 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. | 99315 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Nursing facility discharge management; 30 minutes or less total time on the date of the encounter | 99316 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Nursing facility discharge management; more than 30 minutes total time on the date of the encounter | 99341 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. | 99342 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99344 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. | 99345 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. | 99347 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. | 99348 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99349 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. | 99350 | Telehealth Service (Medicare) MPFS Status: Active Code APC B Physician Quality Reporting PUB 100 CPT Assistant Article Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. | 99366 | MPFS Status: Bundled Code APC N PUB 100 CPT Assistant Article Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional | 99374 | MPFS Status: Bundled Code APC B PUB 100 CPT Assistant Article Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes | 99375 | MPFS Status: Not valid for Medicare purposes APC E1 PUB 100 CPT Assistant Article Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more | 99377 | MPFS Status: Bundled Code APC B PUB 100 CPT Assistant Article Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes | 99378 | MPFS Status: Not valid for Medicare purposes APC E1 PUB 100 CPT Assistant Article Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more | 99379 | MPFS Status: Bundled Code APC B PUB 100 CPT Assistant Article Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes | 99380 | MPFS Status: Bundled Code APC B PUB 100 CPT Assistant Article Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more | 99381 | Age Edit MPFS Status: Non-covered Service APC E1 PUB 100 CPT Assistant Article Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) | 99382 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) | 99383 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) | 99384 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) | 99385 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years | 99386 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years | 99387 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older | 99391 | Age Edit MPFS Status: Non-covered Service APC E1 PUB 100 CPT Assistant Article Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) | 99392 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) | 99393 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) | 99394 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) | 99395 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years | 99396 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years | 99397 | Age Edit MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older | 99401 | MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes | 99402 | MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes | 99403 | MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes | 99404 | MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes | 99406 | Telehealth Service (Medicare) Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Active Code APC S PUB 100 CPT Assistant Article Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes | 99407 | Telehealth Service (Medicare) Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Active Code APC S PUB 100 CPT Assistant Article Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes | 99408 | Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Non-covered Service APC E1 PUB 100 CPT Assistant Article Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes | 99409 | Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Non-covered Service APC E1 PUB 100 CPT Assistant Article Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes | 99411 | MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes | 99412 | MPFS Status: Non-covered Service APC E1 Physician Quality Reporting PUB 100 CPT Assistant Article Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes | 99415 | Addon Code Resequenced Code MPFS Status: Active Code APC B Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) | 99416 | Addon Code Resequenced Code MPFS Status: Active Code APC B Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service) | 99460 | 0-3 months MPFS Status: Active Code APC V CPT Assistant Article Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant | 99461 | MPFS Status: Active Code APC M Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center | 99462 | MPFS Status: Active Code APC C Subsequent hospital care, per day, for evaluation and management of normal newborn | 99463 | MPFS Status: Active Code APC V CPT Assistant Article Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date | 99466 | MPFS Status: Active Code APC N CPT Assistant Article Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport | 99467 | Addon Code MPFS Status: Active Code APC N CPT Assistant Article Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; each additional 30 minutes (List separately in addition to code for primary service) | 99468 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger | 99469 | Telehealth Service (Medicare) MPFS Status: Active Code APC C Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger | 99471 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age | 99472 | Telehealth Service (Medicare) MPFS Status: Active Code APC C Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age | 99475 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age | 99476 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age | 99477 | Age Edit Telehealth Service (Medicare) MPFS Status: Active Code APC C PUB 100 CPT Assistant Article Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services | 99478 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams) | 99479 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams) | 99480 | Telehealth Service (Medicare) MPFS Status: Active Code APC C CPT Assistant Article Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams) | 99487 | MPFS Status: Active Code APC S Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. | 99489 | Addon Code MPFS Status: Active Code APC N Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) | 99490 | Resequenced Code MPFS Status: Active Code APC S Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. | 99491 | Resequenced Code MPFS Status: Active Code APC M Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. | 99492 | MPFS Status: Active Code APC S Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional, initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan, review by the psychiatric consultant with modifications of the plan if recommended, entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant, and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies. | 99493 | MPFS Status: Active Code APC S Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation, participation in weekly caseload consultation with the psychiatric consultant, ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers, additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant, provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies, monitoring of patient outcomes using validated rating scales, and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment. | 99494 | Addon Code MPFS Status: Active Code APC N Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) | 99495 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC V Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge At least moderate level of medical decision making during the service period Face-to-face visit, within 14 calendar days of discharge | 99496 | Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC V Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge High level of medical decision making during the service period Face-to-face visit, within 7 calendar days of discharge | 99497 | Telehealth Service (Medicare) Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Active Code APC Q1 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate | 99498 | Telehealth Service (Medicare) Addon Code Telemedicine Service (AMA) Audio-Only Telemedicine (AMA) MPFS Status: Active Code APC N Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) | CCCCC | 1 | G0463 | Medicare Coverage: Carrier Priced MPFS Status: Statutory exclusion (from MPFS, may be paid under other methodologies) APC J2 Hospital outpatient clinic visit for assessment and management of a patient |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GW | Service not related to the hospice patient's terminal condition | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 93 | Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GZ | Item or service expected to be denied as not reasonable and necessary | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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